Bank holiday staff shortages partially blamed for 7 year-old's death


A report has found that Good Friday shortages in nursing staff contributed to the death after heart surgery of a 7 year-old Cardiff boy.

A corrective operation undergone by Luke Jenkins at Bristol Children's Hospital on 6 April was considered successful and the youngster was expected to make a full recovery.

Medical errors led to boy's death from staffing shortages

However, an inquiry by University Hospitals Bristol NHS Foundation Trust (UHBFT) revealed that "avoidable errors" led to Luke's death the following day.

Luke, who was born with a congenital heart defect and had already twice undergone corrective surgery, collapsed after suffering a cardiac arrest on Good Friday. The duty surgeon, who was at home, was called to the hospital urgently and was able to treat Luke within 20 minutes.

However, the boy's heart stopped for 43 minutes before resuscitation and he was given exploratory surgery. He died 1 day later.

The report, parts of which have been questioned by Luke's parents, found that time was lost because junior nurses did not know the whereabouts in Luke's ward of resuscitation equipment.

The investigation also found that since cardiac arrest was unusual in the ward environment, the equipment was unfamiliar to the emergency team.

After several days in intensive care Luke was transferred to the hospital's ward 32, which the report found had been affected by staff shortages for "at least 2 years".

Despite a serious incident in October 2010, an assessment identifying "low and unsafe" nurse staffing and high-dependency patient monitoring had not been dealt with, according to the report.

It was also found that Luke's monitoring equipment alarms were re-set due to the youngster frequently triggering them after he was admitted to ward 32.

Claiming the report itself is flawed, Luke's parents questioned the assertion that their son had been x-rayed the day before he died.

"If he had had an x-ray they would have found what was wrong with him and he would still be here now," said Mr Jenkins. "But we were with him all day and we know that it never happened."

Noting that 8 other staffing-related incidents have occurred since January 2012, Mr Jenkins added: "They cannot tell us who the people were but that should be made public."

Expressing the trust's sympathy to the family, UHBFT acting chief executive Deborah Lee said: "We are aware of their concerns about the care their child received and are investigating those concerns. Incidents do occur in a complex specialty such as paediatric cardiac services, where we are caring for some of the sickest children in the region."

Ms Lee insisted that all incidents are recorded, investigated and acted upon, no matter how minor they might appear, as part of its process of clinical governance.

"We provide highly specialist care for children with a range of complex cardiac problems from south Wales and the south-west and our reported cardiac outcomes are amongst the best in the UK."

News Archive

Get In Touch